Medical Emergencies

A patient is brought to the ED by a friend, who states that a tree fell on the patient's leg and crushed it while they were cutting firewood. What priority actions should the nurse perform? (Select all that apply.)

apply a clean dressing to protect the wound elevating the site to limit accumulation of fluid in the interstitial spaces splinting the wound in a position of rest to prevent motion

The intensive care unit nurse is assessing a client who is going to require a peripheral intravenous (PIV) line for fluids. The nurse should consider what information in the client's health history when deciding the site for the PIV? a. The client has a fluid volume restriction b. The client has hypertension c. The client has had a mastectomy on the right side d. The client has a history of falls

the client has had a mastectomy on the right side

When providing care to a client who has experienced multiple trauma, which of the following would be most important for the nurse to keep in mind?

the client is assumed to have a SCI until proven otherwise

The nurse is caring for a client who is being prepared for the placement of a central intravenous line. The nurse recognizes this client requires this type of intravenous access for which reason?

the client requires TPN

An ED nurse has just received a call from EMS that they are transporting a 17-year-old man who has just sustained a spinal cord injury (SCI). The nurse recognizes that the most common cause of this type of injury is what? A) Sports-related injuries B) Acts of violence C) Injuries due to a fall D) Motor vehicle accidents

MVAs

A patient has experienced an electrical burn and has developed thick eschar over the burn site. Which of the following topical antibacterial agents will the nurse expect the physician to order for the wound? A) Silver sulfadiazine 1% (Silvadene) water-soluble cream B) Mafenide acetate 10% (Sulfamylon) hydrophilic-based cream C) Silver nitrate 0.5% aqueous solution D) Acticoat

Mafenide acetate 10% (Sulfamylon) hydrophilic-based cream

The nurse is caring for a client in the ED with frostbite to the left hand. During the rewarming process of the hand, the nurse should perform which action? a. Administer analgesic medications as ordered. b. Rupture any hemorrhagic blebs that are noted. c. Keep the hand in the circulating bath for 1 hour. d. Have the client complete active range-of-motion exercises.

administer analgesic meds as ordered

A group of medical nurses are being certified in their response to potential bioterrorism. The nurses learn that if a patient is exposed to the smallpox virus he or she becomes contagious at what time? A. 6 to 12 hours after exposure B. When pustules form C. After a rash appears D. When the patient becomes febrile

after a rash appears

The emergency response team is dealing with a radiation leak at the hospital. What action should be performed to prevent the spread of the contaminants? A. Floors must be scrubbed with undiluted bleach. B. Waste must be promptly incinerated. C. The ventilation system should be deactivated. D. Air ducts and vents should be sealed.

air ducts and vents should be sealed

A patient is brought to the ED by paramedics, who report that the patient has partial-thickness burns on the chest and legs. The patient has also suffered smoke inhalation. What is the priority in the care of a patient who has been burned and suffered smoke inhalation? A) Pain B) Fluid balance C) Anxiety and fear D) Airway management

airway management

Level C personal protective equipment has been deemed necessary in the response to an unknown substance. The nurse is aware that the equipment will include what? A. A self-contained breathing apparatus B. A vapor-tight, chemical-resistant suit C. A uniform only D. An air-purified respirator

an air-purified respirator

A nurse who is a member of the local disaster response team is learning about blast injuries. The nurse should plan for what event that occurs in the tertiary phase of the blast injury? A. Victims pre-existing medical conditions are exacerbated. B. Victims are thrown by the pressure wave. C. Victims experience burns from the blast. D. Victims suffer injuries caused by debris or shrapnel from the blast.

victims are thrown by the pressure wave

An occupational health nurse is called to the floor of a factory where a worker has sustained a flash burn to the right arm. The nurse arrives and the flames have been extinguished. The next step is to "cool the burn." How should the nurse cool the burn? A) Apply ice to the site of the burn for 5 to 10 minutes. B) Wrap the patient's affected extremity in ice until help arrives. C) Apply an oil-based substance or butter to the burned area until help arrives. D) Wrap cool towels around the affected extremity intermittently.

wrap cool towels around the affected extremity intermittently

A nurse is preparing to assist with a gastric lavage for a client who has ingested an unknown poison and is obtunded. To ensure that the tube reaches the stomach, the nurse would measure the distance from the bridge of the nose to which of the following? a. Umbilicus b. Ear lobe c. Xiphoid process d. Chin

xiphoid process

The school nurse is giving a presentation on preventing spinal cord injuries (SCI). What should the nurse identify as prominent risk factors for SCI? Select all that apply. A) Young age B) Frequent travel C) African American race D) Male gender E) Alcohol or drug use

young age male gender alcohol or drug use

The nurse in the hospital emergency department is assessing a patient who fell while intoxicated with alcohol. The nurse is using the Clinical Institute Withdrawal Assessment-Alcohol (CIWA-A) scale to assess the patient's need for a benzodiazipine medication. In order to assess for auditory disturbances, which question should the nurse ask the patient?

"Are you hearing anything that is disturbing you?

A nurse who is taking care of a patient with burns is asked by a family member why the patient is losing so much weight. The patient is currently in the intermediate phase of recovery. What would be the nurse's most appropriate response to the family member? A) "He's on a calorie-restricted diet in order to divert energy to wound healing." B) "His body has consumed his fat deposits for fuel because his calorie intake is lower than normal." C) "He actually hasn't lost weight. Instead, there's been a change in the distribution of his body fat." D) "He lost many fluids while he was being treated in the emergency phase of burn care."

"His body has consumed his fat deposits for fuel because his calorie intake is lower than normal"

The nurse has complete discharge instructions for a client w/ application of a halo device who sustained a cervical SCI. Which statement indicates the client needs further clarification of the instructions? 1. "I will use a straw for drinking" 2. "I will drive only during the daytime" 3. "I will be careful because the device alters balance" 4. "I will wash the skin daily under the lamb's wool liner of the vest"

"I will drive only during the daytime"

The nurse is caring for a client in the ED following a sexual assault. The client is hysterical and crying. The client states, "I know I'm pregnant now, maybe I have HIV. Why did this happen to me?" Which is the best response by the nurse?

"Let's talk about this. Do you want me to call a support person?"

A burn patient is transitioning from the acute phase of the injury to the rehabilitation phase. The patient tells the nurse, "I can't wait to have surgery to reconstruct my face so I look normal again." What would be the nurse's best response? A) "That's something that you and your doctor will likely talk about after your scars mature." B) "That is something for you to talk to your doctor about because it's not a nursing responsibility." C) "I know this is really important to you, but you have to realize that no one can make you look like you used to." D) "Unfortunately, it's likely that you will have most of these scars for the rest of your life."

"That's something that you and your doctor will likely talk about after your scars mature"

The nurse is providing health education to a patient who has a C6 spinal cord injury. The patient asks why autonomic dysreflexia is considered an emergency. What would be the nurse's best answer? A) "The sudden increase in BP can raise the ICP or rupture a cerebral blood vessel." B) "The suddenness of the onset of the syndrome tells us the body is struggling to maintain its normal state." C) "Autonomic dysreflexia causes permanent damage to delicate nerve fibers that are healing." D) "The sudden, severe headache increases muscle tone and can cause further nerve damage."

"The sudden increase in BP can raise the ICP or rupture a cerebral blood vessel"

The nurse is caring for an intensive care unit client who has died with family members at the bedside. The death was sudden and unexpected resulting from a car accident that took place three days ago. The family is upset and the client's partner, crying loudly, yells, "How did this happen? We were just about to celebrate his birthday. He can't be gone!" The family member continues to cry inconsolably. How should the nurse respond? a." I will get you some medication that will help you feel more calm." b."It is important to face the reality that he is gone." c. "He has passed on to a better place now." d. "We did everything we could possibly do to try to save his life."

"We did everything we could possibly due to try to save his life"

A patient is brought to the emergency department. Assessment reveals that the patient is lethargic and diaphoretic and complaining of right upper quandrant pain. Acetaminophen toxicity is suspected and an acetaminophen level is drawn. Which result would the nurse interpret as indicating toxicity for the patient if he weighs 70 kg?

10,500 mg

A client suspected of acetaminophen (Tylenol) toxicity reports that he ingested the medication at 7 p.m. At what time should the nurse anticipate laboratory tests to assess the acetaminophen level?

11:00 pm

A patient arrives in the emergency department after being burned in a house fire. The patient's burns cover the face and the left forearm. What extent of burns does the patient most likely have? A) 13% B) 25% C) 9% D) 18%

18%

A nurse on a burn unit is caring for a patient in the acute phase of burn care. While performing an assessment during this phase of burn care, the nurse recognizes that airway obstruction related to upper airway edema may occur up to how long after the burn injury? A) 2 days B) 3 days C) 5 days D) 1 week

2 days

Permanent brain injury or death will occur within which time frame secondary to hypoxia?

3 to 5 minutes

The nurse is caring for a patient whose spinal cord injury has caused recent muscle spasticity. What medication should the nurse expect to be ordered to control this? A) Baclofen (Lioresal) B) Dexamethasone (Decadron) C) Mannitol (Osmitrol) D) Phenobarbital (Luminal)

Baclofen (Lioresal)

The nurse is conducting a secondary survey on a client in the ED. Which action is completed during the secondary survey?

DX and lab testing

A patient's burns are estimated at 36% of total body surface area; fluid resuscitation has been ordered in the emergency department. After establishing intravenous access, the nurse should anticipate the administration of what fluid? A) 0.45% NaCl with 20 mEq/L KCl B) 0.45% NaCl with 40 mEq/L KCl C) Normal saline D) Lactated Ringer's

Lactated Ringer's

Acetaminophen overdose is treated with administration of which medication? a. Diazepam b. Naloxone c. Flumazenil d. N-acetylcysteine

N-acetylcysteine

A home care nurse is performing a visit to a patient's home to perform wound care following the patient's hospital treatment for severe burns. While interacting with the patient, the nurse should assess for evidence of what complication? A) Psychosis B) Post-traumatic stress disorder C) Delirium D) Vascular dementia

PTSD

A nurse is caring for a patient who has sustained a deep partial-thickness burn injury. In prioritizing the nursing diagnoses for the plan of care, the nurse will give the highest priority to what nursing diagnosis? A) Activity Intolerance B) Anxiety C) Ineffective Coping D) Acute Pain

acute pain

An emergency department nurse has just received a patient with burn injuries brought in by ambulance. The paramedics have started a large-bore IV and covered the burn in cool towels. The burn is estimated as covering 24% of the patient's body. How should the nurse best address the pathophysiologic changes resulting from major burns during the initial burn-shock period? A) Administer IV fluids B) Administer broad-spectrum antibiotics C) Administer IV potassium chloride D) Administer packed red blood cells

admin IV fluids

The ED staff work collaboratively and follow the ABCDE method to establish and treat health priorities effectively in a client experiencing a trauma. Which action is completed by the nurse when implementing the "D" element of this method? a. Providing cervical spine protection b. Assessing the client's Glasgow Coma Scale score c. Managing hypothermia d. Undressing the client quickly

assessing the client's GCS

A patient who has been exposed to anthrax is being treated in the local hospital. The nurse should prioritize what health assessments? A. Integumentary assessment B. Assessment for signs of hemorrhage C. Neurologic assessment D. Assessment of respiratory status

assessment of respiratory status

A client has a gaping wound on his forearm that is bleeding profusely. Applying pressure to which pressure point would be most helpful? a. Subclavian b. Femoral c. Radial d. Brachial

brachial

A nurse is caring for a critically ill patient with autonomic dysreflexia. What clinical manifestations would the nurse expect in this patient? A) Respiratory distress and projectile vomiting B) Bradycardia and hypertension C) Tachycardia and agitation D) Third-spacing and hyperthermia

bradycardia and HTN

The nurse is caring for a client who is agitated and confused. The client is persistently trying to get out of bed and attempted to remove the peripheral IV. The nurse has attempted to re-orient the client; however, this was not effective in de-escalating the client's agitation. The client yells, "I am going to punch you in the face!" What is the nurse's next action?

call security personnel to assist

When assessing a client with suspected carbon monoxide poisoning, which finding would be least reliable?

cherry red skin color

A nurse is teaching a patient with a partial-thickness wound how to wear his elastic pressure garment. How would the nurse instruct the patient to wear this garment? A) 4 to 6 hours a day for 6 months B) During waking hours for 2 to 3 months after the injury C) Continuously D) At night while sleeping for a year after the injury

continuously

The health care team in an intensive care unit have experienced a critical incident in which a young client died unexpectedly and the client's father physically attacked the senior physician treating the client. The client's father was arrested and escorted from the intensive care unit by police, against his will and in handcuffs. A critical incident stress management (CISM) staff meeting held 3 days after the incident took place. What would be the purpose for that meeting?

debriefing

A patient with severe burns is admitted to the intensive care unit to stabilize and begin fluid resuscitation before transport to the burn center. The nurse should monitor the patient closely for what signs of the onset of burn shock? A) Confusion B) High fever C) Decreased blood pressure D) Sudden agitation

decreased BP

A client is brought to the emergency department after being involved in a motor vehicle collision. Which of the following would lead the nurse to suspect internal bleeding?

delayed capillary refill

The announcement is made that the facility may return to normal functioning after a local disaster. In the emergency operations plan, what is this referred to as? A. Demobilization response B. Post-incident response C. Crisis diffusion D. Reversion

demobilization response

The nurse is preparing a nursing care plan for a client w/ a SCI for whom problems of decreased mobility and inability to perform ADLs have been identified. The client tells the nurse, "I don't know why we're doing all this. My life's over." Based on this statement, which additional nursing concern takes priority? 1. risk for injury 2. decreased nutrition 3. difficulty w/ coping 4. impairment of body image

difficulty w/ coping

A nurse is undergoing debriefing with the critical incident stress management (CISM) team after participating in the response to a disaster. During this process, the nurse will do which of the following? A. Evaluate the care that he or she provided during the disaster. B. Discuss own emotional responses to the disaster. C. Explore the ethics of the care provided during the disaster. D. Provide suggestions for improving the emergency operations plan.

discuss own emotional responses to the disaster

A client presents to the ED reporting choking on a chicken bone. The client is breathing spontaneously. The nurse applies oxygen and suspects a partial airway obstruction. Which action should the nurse do next?

encourage the client to cough forcefully

A nurse is caring for a patient with multiple injuries and performs the following. Place these actions in the order in which the nurse would perform them. Use all options.

establish airway and ventilation control hemorrhage prevent and treat shock assess for head and neck injuries assess for abdomen, back, and extremity injuries spint fractures

A patient arrives at the emergency department after taking more than 20 lorazepam tablets. Which of the following would the nurse anticipate that the patient would be given to reverse the effects of the drug?

flumazenil

A patient is brought to the emergency department from the site of a chemical fire, where he suffered a burn that involves the epidermis, dermis, and the muscle and bone of the right arm. On inspection, the skin appears charred. Based on these assessment findings, what is the depth of the burn on the patient's arm? A) Superficial partial-thickness B) Deep partial-thickness C) Full partial-thickness D) Full-thickness

full-thickness

Nursing students are reviewing the categories of intra-abdominal injuries. The students demonstrate understanding of the information when they identify which of the following as examples of penetrating trauma? Select all that apply. a. Being struck with a baseball bat b. Motor-vehicle crash c. Gunshot wound d. Knife-stab wound e. Fall from a roof

gunshot wound knife-stab wound

A patient is brought to the emergency department after being locked outside of her house in the frigid weather for several hours. The nurse suspects that the patient has sustained frostbite of her hand based on which of the following findings?

hand that is insensitive to touch

A nurse is caring for a client who has arrived at the emergency department in shock. The nurse intervenes based on the knowledge that which of the following is the most common cause of shock?

hypovolemia

A triage nurse in the emergency department (ED) receives a phone call from a frantic father who saw his 4-year-old child tip a pot of boiling water onto her chest. The father has called an ambulance. What would the nurse in the ED receiving the call instruct the father to do? A) Cover the burn with ice and secure with a towel. B) Apply butter to the area that is burned. C) Immerse the child in a cool bath. D) Avoid touching the burned area under any circumstances.

immerse the child in a cool bath

The ED staff has been notified of the imminent arrival of a patient who has been exposed to chlorine. The nurse should anticipate the need to address what nursing diagnosis? A. Impaired gas exchange B. Decreased cardiac output C. Chronic pain D. Excess fluid volume

impaired gas exchange

There has been a radiation-based terrorist attack and a patient is experiencing vomiting, diarrhea, and shock after the attack. How will the patients likelihood of survival be characterized? A. Probable B. Possible C. Improbable D. Extended

improbable

A nurse is completing her annual cardiopulmonary resuscitation training. The class instructor tells her that a client has fallen off a ladder and is lying on his back; he is unconscious and isn't breathing. What maneuver should the nurse use to open his airway? a. Jaw-thrust b. Abdominal thrust c. Seldinger d. Head tilt-chin lift

jaw-thrust

A client w/ a SCI is prone to experiencing autonomic dysreflexia. The nurse should include which measures in the plan of care to minimize the risk of occurrence? SATA 1. keeping the linens wrinkle free under the client 2. preventing unnecessary pressure on the lower limbs 3. limiting bladder catheterization to once every 12 hours 4. turning and repositioning the client at least every 2 hours 5. ensuring that the client has a bowel movement at least once a week

keeping the linens wrinkle free under the client preventing unnecessary pressure on the lower limbs turning and repositioning the client at least every 2 hours

Which solution should the nurse use to replace lost fluids in a client with signs and symptoms of shock due to hemorrhaging?

lactated ringer's solution

Following a spinal cord injury a patient is placed in halo traction. While performing pin site care, the nurse notes that one of the traction pins has become detached. The nurse would be correct in implementing what priority nursing action? A) Complete the pin site care to decrease risk of infection. B) Notify the neurosurgeon of the occurrence. C) Stabilize the head in a lateral position. D) Reattach the pin to prevent further head trauma.

notify the neurosurgeon of the occurrence

A nurse is providing care to a client in the emergency department and walks into the hallway to get equipment. All of a sudden, gunshots are heard. Which of the following would be the nurse's priority?

protecting himself or herself

The nurse is providing care for a client who was admitted to the intensive care unit after suffering cardiovascular collapse secondary to a methamphetamine overdose. The client is semi-conscious and has a nasopharyngeal in place. The nurse anticipates this client may require which interventions? Select all that apply.

provide airway support and ventilation minimize lights and noise disturbances admin antipsychotic med follow unit seizure protocol

The nurse is caring for a client who is at risk for suicide. What is the priority nursing action for this client? 1. provide authority, action, and participation 2. display an attitude of detachment, confrontation, and efficiency 3. demonstrate confidence in the client's ability to deal w/ stressors 4. provide hope and reassurance that the problems will resolves themselves

provide authority, action, and participation

The nurse has received a client into care who was admitted with a heroin overdose. The client has a 5-year history of illicit substance use with cocaine, heroine and oxycodone. The client develops a sudden onset of wheezing, restlessness and a cough that produces a frothy, pink sputum. The nurse suspects the client has most likely developed which complication of opioid overdose?

pulmonary edema

The nurse manager in the ED receives information that a local chemical plant has had a chemical leak. This disaster is assigned a status of level II. What does this classification indicate? A. First responders can manage the situation. B. Regional efforts and aid from surrounding communities can manage the situation. C. Statewide or federal assistance is required. D. The area must be evacuated immediately.

regional efforts and aid from surrounding communities can manage the situation

A client comes to the ED after an assault and is extremely agitated, trembling, and hyperventilating. What is the priority nursing action for this client? 1. begin to teach relaxation techniques 2. encourage the client to discuss the assault 3. remain w/ the client until the anxiety decreases 4. place the client in a quiet room alone to decrease stimulation

remain w/ the client until the anxiety decreases

A nurse is establishing a patient's airway. Which action would the nurse perform first?

repositioning the patient's head

A patient is admitted to the neurologic ICU with a spinal cord injury. When assessing the patient the nurse notes there is a sudden depression of reflex activity in the spinal cord below the level of injury. What should the nurse suspect? A) Epidural hemorrhage B) Hypertensive emergency C) Spinal shock D) Hypovolemia

spinal shock

Following a motor vehicle collision, a client is brought to the ED for evaluation and treatment. The client is being assessed for intra-abdominal injuries. The client reports severe left shoulder pain (pain score of 10 on a 1 to 10 scale). The nurse suspects injury to the

spleen

A nurse is assessing a patient who is suspected of having a partial airway obstruction. Which of the following would the nurse expect to find? a. Severe respiratory distress b. High-pitched noises on inhalation c. Spontaneous coughing d. Cyanosis

spontaneous coughing

A client comes to the emergency department after experiencing a wound. Inspection reveals an opening in the skin with distinct edges and whose depth is greater than the length of the wound. The nurse documents this as which type of wound?

stab

A nurse is giving an educational class to members of the local disaster team. What should the nurse instruct members of the disaster team to do in a chemical bioterrorist attack? A. Cover their eyes. B. Put on a personal protective equipment mask. C. Stand up. D. Crawl to an exit.

stand up

Which of the following would the nurse identify as indicating that a client is experiencing a complete airway obstruction? Select all that apply.

stridor cyanosis clutching of the neck inability to speak

An emergency department nurse learns from the paramedics that they are transporting a patient who has suffered injury from a scald from a hot kettle. What variables will the nurse consider when determining the depth of burn? A) The causative agent B) The patient's preinjury health status C) The patient's prognosis for recovery D) The circumstances of the accident

the causative agent

A nurse is caring for a client who is experiencing alcohol withdrawal. Which statement best indicates that the client understands the need for long-term treatment? a. The client agrees to attend supportive counseling b. The client agrees to ongoing participation in one or more support groups. c. The client agrees to detoxification, rehabilitation, and participation in an aftercare program. d. The client agrees to involve his family in psychotherapy.

the client agrees to detoxification, rehabilitation, and participation in an aftercare program

What is a common source of airway obstruction in an unconscious client? a. A foreign object b. The tongue c. edema d. Saliva or mucus

the tongue

A client present to the ED following a work-related injury to the left hand. The client has an avulsion of the left ring finger. Which correctly describes an avulsion? a. Tissue tearing away from supporting structures b. Incision of the skin with well-defined edges, usually long rather than deep c. Denuded skin d. Skin tear with irregular edges and vein bridging

tissue tearing away from supporting structures

A triage nurse in the ED determines that a patient with dyspnea and dehydration is not in a life-threatening situation. What triage category will the nurse choose?

urgent

A patient is brought to the emergency department with a burn injury. The nurse knows that the first systemic event after a major burn injury is what? A) Hemodynamic instability B) Gastrointestinal hypermotility C) Respiratory arrest D) Hypokalemia

hemodynamic instability

A client presents to the ED following a chemical burn. The client identifies the source of the burn as white phosphorus. The nurse knows that treatment will include

no application of water to the burn

A nurse has reported for a shift at a busy burns and plastics unit in a large university hospital. Which patient is most likely to have life-threatening complications? A) A 4-year-old scald victim burned over 24% of the body B) A 27-year-old male burned over 36% of his body in a car accident C) A 39-year-old female patient burned over 18% of her body D) A 60-year-old male burned over 16% of his body in a brush fire

a 4 y/o scald victim burned over 24% of the body

A patient who is in the acute phase of recovery from a burn injury has yet to experience adequate pain control. What pain management strategy is most likely to meet this patient's needs? A) A patient-controlled analgesia (PCA) system B) Oral opioids supplemented by NSAIDs C) Distraction and relaxation techniques supplemented by NSAIDs D) A combination of benzodiazepines and topical anesthetics

a PCA system

The nurse employed in an ED is assigned to triage clients coming to the ED for treatment on the evening shift. The nurse should assign priority to which client? 1. a client c/o muscle aches, a headache, and a HX of seizures 2. a client who twisted her ankle when rollerblading and is requesting medication for pain 3. a client w/ a minor laceration of the index finger sustained while cutting an eggplant 4. a client w/ chest pain who states that he just ate pizza that was made w/ a very spicy sauce

a client w/ chest pain who states that he just ate pizza that was made w/ a very spicy sauce

After a radiation exposure, a patient has been assessed and determined to be a possible survivor. Following the resolution of the patients initial symptoms, the care team should anticipate what event? A. A return to full health B. Internal bleeding C. A latent phase D. Massive tissue necrosis

a latent phase

The nurse is the first responder after a tornado has destroyed many homes in the community. Which victim should the nurse attend to first? 1. a pregnant woman who exclaims, "My baby is not moving" 2. a woman who is complaining, "My leg is bleeding so bad I am afraid it is going to fall off" 3. a young child standing next to an adult family member who is screaming "I want my mommy" 4. an older victim who is sitting next to her husband sobbing, "My husband is dead. My husband is dead"

a woman who is complaining, "My leg is bleeding so bad I am afraid it is going to fall off"

The current phase of a patient's treatment for a burn injury prioritizes wound care, nutritional support, and prevention of complications such as infection. Based on these care priorities, the patient is in what phase of burn care? A) Emergent B) Immediate resuscitative C) Acute D) Rehabilitation

acute

The nurse is providing care for a client who is experiencing alcohol withdrawal. The client reports, "I cannot fall or stay asleep." The nurse observes that the client is agitated, having difficulty falling asleep and crying uncontrollably, with confused speech and a tachycardic pulse. Which intervention should the nurse implement first?

admin lorazepam as ordered by the HCP

A patient has been admitted to the medical unit with signs and symptoms that are suggestive of anthrax infection. The nurse should anticipate what intervention? A. Administration of acyclovir B. Hematopoietic stem cell transplantation (HSCT) C. Administration of penicillin D. Hemodialysis

admin of penicillin

A patient with frostbite to both lower extremities from exposure to the elements is preparing to have rewarming of the extremities. What intervention should the nurse provide prior to the procedure? a. Administer an analgesic as ordered. b. Elevate the legs. c. Massage the extremities. d. Apply a heat lamp.

administer an analgesic as ordered

A patient with a T2 injury is in spinal shock. The nurse will expect to observe what assessment finding? A) Absence of reflexes along with flaccid extremities B) Positive Babinski's reflex along with spastic extremities C) Hyperreflexia along with spastic extremities D) Spasticity of all four extremities

absence of reflexes along w/ flaccid extremities

A nurse who provides care on a burn unit is preparing to apply a patient's ordered topical antibiotic ointment. What action should the nurse perform when administering this medication? A) Apply the new ointment without disturbing the existing layer of ointment. B) Apply the ointment using a sterile tongue depressor. C) Apply a layer of ointment approximately 1/16 inch thick. D) Gently irrigate the wound bed after applying the antibiotic ointment.

apply a layer of ointment approx. 1/16 inch thick

The nurse received a patient from a motor vehicle accident who is hemorrhaging from a femoral wound. What is the initial nursing action for the control of the hemorrhage?

apply firm pressure over the involved area or artery

As part of an emergency department team, an emergency nurse is conducting a secondary survey on a client. Which of the following would the nurse include?

applying ECG electrodes

A patient with spinal cord injury has a nursing diagnosis of altered mobility and the nurse recognizes the increased the risk of deep vein thrombosis (DVT). Which of the following would be included as an appropriate nursing intervention to prevent a DVT from occurring? A) Placing the patient on a fluid restriction as ordered B) Applying thigh-high elastic stockings C) Administering an antifibrinolyic agent D) Assisting the patient with passive range of motion (PROM) exercises

applying thigh-high elastic stockings

A nurse is providing care to the family of a client who was brought to the emergency department and suddenly died. Which of the following would be appropriate for the nurse to do? Select all that apply.

ask the family if the would like to view the body provide a private place for the family to be together allow the family to express their emotions freely

A female patient was sexually assaulted when leaving work. When assisting with the physical examination, what nursing interventions should be provided? (Select all that apply.)

assess and document any bruises and lacerations record a HX of the event, using the patient's own words label all torn or bloody clothes and place each item in a separate bag so that any evidence can be given to the police

A patient has experienced burns to his upper thighs and knees. Following the application of new wound dressings, the nurse should perform what nursing action? A) Instruct the patient to keep the wound site in a dependent position. B) Administer PRN analgesia as ordered. C) Assess the patient's peripheral pulses distal to the dressing. D) Assist with passive range of motion exercises to "set" the new dressing.

assess the patient's peripheral pulses distal to the dressing

A nurse is performing a home visit to a patient who is recovering following a long course of inpatient treatment for burn injuries. When performing this home visit, the nurse should do which of the following? A) Assess the patient for signs of electrolyte imbalances. B) Administer fluids as ordered. C) Assess the risk for injury recurrence. D) Assess the patient's psychosocial state.

assess the patient's psychosocial state

The nurse is admitting a patient with a penetrating abdominal injury from a knife wound. What should the nursing measures for a penetrating abdominal injury include? (Select all that apply.)

assessing for manifestations of hemorrhage covering any protruding viscera w/ sterile dressings soaked in normal saline solution looking for any associated chest injuries

A patient is admitted to the ED who has been exposed to a nerve agent. The nurse should anticipate the STAT administration of what drug? A. Amyl nitrate B. Dimercaprol C. Erythromycin D. Atropine

atropine

A homeless client presents to the ED. Upon assessment, the client is experiencing hypothermia. The nurse will plan to complete which priority intervention during the rewarming process?

attach a cardiac monitor

A workplace explosion has left a 40-year-old man burned over 65% of his body. His burns are second and third-degree burns, but he is conscious. How would this person be triaged? A. Green B. Yellow C. Red D. Black

black

A patient working in a chemical facility sustains a chemical burn to his arms. The chemical involved was white phosphorus. Which of the following would be the priority nursing action?

brushing off all traces of the chemical from the patient's skin

A client is brought to the emergency department with severe hemorrhage requiring massive blood replacement. The nurse warms the blood in a commercial warmer based on the understanding that infusion of large amounts of blood could result in which of the following?

cardiac arrest

The nurse is planning the care of a patient with a T1 spinal cord injury. The nurse has identified the diagnosis of "risk for impaired skin integrity." How can the nurse best address this risk? A) Change the patient's position frequently. B) Provide a high-protein diet. C) Provide light massage at least daily. D) Teach the patient deep breathing and coughing exercises.

change the patient's position frequently

A patient with a C5 spinal cord injury is tetraplegic. After being moved out of the ICU, the patient complains of a severe throbbing headache. What should the nurse do first? A) Check the patient's indwelling urinary catheter for kinks to ensure patency. B) Lower the HOB to improve perfusion. C) Administer analgesia. D) Reassure the patient that headaches are expected after spinal cord injuries.

check the patient's indwelling urinary catheter for kinks to ensure patency

The nurse is floated from the ED to the neuro floor. Which action should the nurse delegate to the UAP when providing nursing care for a client w/ a SCI? 1. assessing the client's respiratory statues q4h 2. checking and recording the client's VS q4h 3. monitoring the client's nutritional status, including calorie counts 4. instructing the client how to turn, cough, and breathe deeply q2h

checking and recording the client's VS q4h

A client w/ a cervical SCI has been placed in fixed skeletal traction w/ a halo fixation device. When caring for this client, the nurse may assign which actions to the LPN? SATA 1. checking the client's skin for pressure from the device 2. assessing the client's neuro status for changes 3. observing the halo insertion sites for signs of infection 4. cleaning the halo insertion sites w/ hydrogen peroxide 5. developing the nursing plan of care for the client 6. admin oral meds as ordered

checking the client's skin for pressure from the device observing the halo insertion sites for signs of infection cleaning the halo insertion sites w/ hydrogen peroxide admin oral meds as ordered

While developing an emergency operations plan (EOP), the committee is discussing the components of the EOP. During the post-incident response of an emergency operations plan, what activity will take place? A. Deciding when the facility will go from disaster response to daily activities B. Conducting practice drills for the community and facility C. Conducting a critique and debriefing for all involved in the incident D. Replacing the resources in the facility

conducting a critique and debriefing for all involved in the incident

A client presents to the ED following a motor vehicle collision. The client is suspected of having internal hemorrhage. The nurse assesses the client for signs and symptoms of shock. Which are signs and symptoms of shock? Select all that apply.

cool, moist skin decreasing BP delayed capillary refill increasing HR

Which term refers to injuries that occur when a person is caught between objects, run over by a moving vehicle, or compressed by machinery?

crush injuries

A nurse is participating in the planning of a hospitals emergency operations plan. The nurse is aware of the potential for ethical dilemmas during a disaster or other emergency. Ethical dilemmas in these contexts are best addressed by which of the following actions? A. Having an ethical framework in place prior to an emergency B. Allowing staff to provide care anonymously during an emergency C. Assuring staff that they are not legally accountable for care provided during an emergency D. Teaching staff that principles of ethics do not apply in an emergency situation

having an ethical framework in place prior to an emergency

A client is brought to the emergency department by ambulance. The client is seriously ill and unconscious. No family or friends are present. Which of the following would be most appropriate to do?

document the client's condition and absence of friends or family for obtaining consent to treatment

A nurse is triaging patients after a chemical leak at a nearby fertilizer factory. The guiding principle of this activity is what? A. Assigning a high priority to the most critical injuries B. Doing the greatest good for the greatest number of people C. Allocating resources to the youngest and most critical D. Allocating resources on a first come, first served basis

doing the greatest good for the greatest number of people

A patient has sustained a severe burn injury and is thought to have an impaired intestinal mucosal barrier. Since this patient is considered at an increased risk for infection, what intervention will best assist in avoiding increased intestinal permeability and prevent early endotoxin translocation? A) Early enteral feeding B) Administration of prophylactic antibiotics C) Bowel cleansing procedures D) Administration of stool softeners

early enteral feeding

A public health nurse has reviewed local data about the incidence and prevalence of burn injuries in the community. These data are likely to support what health promotion effort? A) Education about home safety B) Education about safe storage of chemicals C) Education about workplace health threats D) Education about safe driving

education about home safety

Which triage category refers to life-threatening or potentially life-threatening injury or illness requiring immediate treatment? a. Immediate b. Non acute c.Emergent d. Urgent

emergent

The nurse caring for a patient who is recovering from full-thickness burns is aware of the patient's risk for contracture and hypertrophic scarring. How can the nurse best mitigate this risk? A) Apply skin emollients as ordered after granulation has occurred. B) Keep injured areas immobilized whenever possible to promote healing. C) Administer oral or IV corticosteroids as ordered. D) Encourage physical activity and range of motion exercises.

encourage physical activity and ROM exercises

A patient has been witness to a disaster involving a large number of injuries. The patient appears upset, but states that he feels capable of dealing with his emotions. What is the nurses most appropriate intervention? A. Educate the patient about the potential harm in denying his emotions. B. Refer the patient to social work or spiritual care. C. Encourage the patient to take a leave of absence from his job to facilitate emotional healing. D. Encourage the patient to return to normal social roles when appropriate.

encourage the patient to return to normal social roles when appropriate

An industrial site has experienced a radiation leak and workers who have been potentially affected are en route to the hospital. To minimize the risks of contaminating the hospital, managers should perform what action? A. Place all potential victims on reverse isolation. B. Establish a triage outside the hospital. C. Have hospital staff put on personal protective equipment. D. Place hospital staff on abbreviated shifts of no more than 4 hours.

establish a triage outside the hospital

For a patient who is experiencing multiple injuries, which sequence of medical or nursing management would the nurse identify as a priority?

establish an airway, control hemorrhage, prevent hypovolemic shock, assess for head injuries

The nurse in the ED is triaging patients during the shift. What does the nurse know is the first priority in treating any patient in the ED?

establishing an airway

Splints have been ordered for a patient who is at risk of developing footdrop following a spinal cord injury. The nurse caring for this patient knows that the splints are removed and reapplied when? A) At the patient's request B) Each morning and evening C) Every 2 hours D) One hour prior to mobility exercises

every 2 hours

The nurse is evaluating the neurological signs of a client w/ spinal shock following an SCI. Which observation indicates that spinal shock persists? 1. hyperreflexia 2. positive reflexes 3. flaccid paralysis 4. reflex emptying of the bladder

flaccid paralysis

A patient has been admitted to a burn intensive care unit with extensive full-thickness burns over 25% of the body. After ensuring cardiopulmonary stability, what would be the nurse's immediate, priority concern when planning this patient's care? A) Fluid status B) Risk of infection C) Nutritional status D) Psychosocial coping

fluid status

A nurse is working as a camp nurse during the summer. A camp counselor comes to the clinic after receiving a snakebite on the arm. What is the first action by the nurse?

have the patient lie down and place the arm below the level of the heart

Which phase of the psychological reaction to rape is characterized by fear and flashbacks? a. Heightened anxiety phase b. Reorganization phase c. Acute disorganization phase d.Denial phase

heightened anxiety phase

A patient in the emergent/resuscitative phase of a burn injury has had blood work and arterial blood gases drawn. Upon analysis of the patient's laboratory studies, the nurse will expect the results to indicate what? A) Hyperkalemia, hyponatremia, elevated hematocrit, and metabolic acidosis B) Hypokalemia, hypernatremia, decreased hematocrit, and metabolic acidosis C) Hyperkalemia, hypernatremia, decreased hematocrit, and metabolic alkalosis D) Hypokalemia, hyponatremia, elevated hematocrit, and metabolic alkalosis

hyperkalemia, hyponatremia, elevated hematocrit, and metabolic acidosis

A patient has been exposed to a nerve agent in a biochemical terrorist attack. This type of agent bonds with acetylcholinesterase, so that acetylcholine is not inactivated. What is the pathologic effect of this type of agent? A. Hyperstimulation of the nerve endings B. Temporary deactivation of the nerve endings C. Binding of the nerve endings D. Destruction of the nerve endings

hyperstimulation of the nerve endings

The nurse caring for a patient with a spinal cord injury notes that the patient is exhibiting early signs and symptoms of disuse syndrome. Which of the following is the most appropriate nursing action? A) Limit the amount of assistance provided with ADLs. B) Collaborate with the physical therapist and immobilize the patient's extremities temporarily. C) Increase the frequency of ROM exercises. D) Educate the patient about the importance of frequent position changes.

increase the frequency of ROM exercises

A patient who has accidentally ingested toilet bowel cleaner is brought to the emergency department. Which action would NOT be appropriate for the nurse to implement? a. Gastric lavage b. Induced vomiting c. Dilution with water or milk d. Administration of activated charcoal

induced vomiting

A patient is admitted to the neurologic ICU with a C4 spinal cord injury. When writing the plan of care for this patient, which of the following nursing diagnoses would the nurse prioritize in the immediate care of this patient? A) Risk for impaired skin integrity related to immobility and sensory loss B) Impaired physical mobility related to loss of motor function C) Ineffective breathing patterns related to weakness of the intercostal muscles D) Urinary retention related to inability to void spontaneously

ineffective breathing patterns related to weakness of the intercostal muscles

A patient's burns have required a homograft. During the nurse's most recent assessment, the nurse observes that the graft is newly covered with purulent exudate. What is the nurse's most appropriate response? A) Perform mechanical débridement to remove the exudate and prevent further infection. B) Inform the primary care provider promptly because the graft may need to be removed. C) Perform range of motion exercises to increase perfusion to the graft site and facilitate healing. D) Document this finding as an expected phase of graft healing.

inform the primary care provider promptly because the graft may need to be removed

A patient is admitted to the neurologic ICU with a spinal cord injury. In writing the patient's care plan, the nurse specifies that contractures can best be prevented by what action? A) Repositioning the patient every 2 hours B) Initiating range-of-motion exercises (ROM) as soon as the patient initiates C) Initiating (ROM) exercises as soon as possible after the injury D) Performing ROM exercises once a day

initiating ROM exercises ASAP after injury

The nurse is caring for a client suffering from carbon monoxide poisoning. The nurse will expect the client to exhibit which manifestation?

intoxication

A patient is admitted to the burn unit after being transported from a facility 1000 miles away. The patient has burns to the groin area and circumferential burns to both upper thighs. When assessing the patient's legs distal to the wound site, the nurse should be cognizant of the risk of what complication? A) Ischemia B) Referred pain C) Cellulitis D) Venous thromboembolism (VTE)

ischemia

A nurse is caring for patients exposed to a terrorist attack involving chemicals. The nurse has been advised that personal protective equipment must be worn in order to give the highest level of respiratory protection with a lesser level of skin and eye protection. What level protection is this considered? A. Level A B. Level B C. Level C D. Level D

level B

A patient arrives at the emergency department after sustaining a gunshot wound to the abdomen. When assessing the patient, the nurse pays particular attention to which of the following?

liver

Which solid organ is most frequently injured in a penetrating trauma? a. Lung b. Pancreas c. Brain d. Liver

liver

A nurse is providing care to an older adult client who has frostbite of the feet. Which action would be least appropriate? a. Massaging the feet b. Placing sterile cotton between the toes after rewarming c. Restricting ambulation d. Providing an analgesic for pain

massaging the feet

A client w/ a SCI at level C3 to C4 is being cared for by the nurse in the ED. What is the priority nursing assessment?

monitor respiratory effort and O2 saturation level

A patient with a spinal cord injury has experienced several hypotensive episodes. How can the nurse best address the patient's risk for orthostatic hypotension? A) Administer an IV bolus of normal saline prior to repositioning. B) Maintain bed rest until normal BP regulation returns. C) Monitor the patient's BP before and during position changes. D) Allow the patient to initiate repositioning.

monitor the patient's BP before and during position changes

Which medication reverses severe respiratory depression and coma? a. Flumazenil b. N-acetylcysteine c. Diazepam d. Naloxone hydrochloride

naloxone

A patient was exposed to a dose of more than 5,000 rads of radiation during a terrorist attack. The patients skin will eventually show what manifestation? A. Erythema B. Ecchymosis C. Desquamation D. Necrosis

necrosis

A patient is being treated in the ED following a terrorist attack. The patient is experiencing visual disturbances, nausea, vomiting, and behavioral changes. The nurse suspects this patient has been exposed to what chemical agent? A. Nerve agent B. Pulmonary agent C. Vesicant D. Blood agent

nerve agent

A group of military nurses are reviewing the care of victims of biochemical terrorist attacks. The nurses should identify what agents as having the shortest latency? A. Viral agents B. Nerve agents C. Pulmonary agents D. Blood agents

nerve agents

The nurse is preparing to transfer a client from the ICU to a medical unit in the hospital. To ensure consistent communication regarding the client's care needs to the receiving unit, in what sequence of steps should the nurse organize the report?

obtain the client's health record state the client's admission date and current DX provide a brief statement of current concerns give the client's pertinent medical HX provide the most recent VS and assessment findings give recommendations for that needs to be done for the client

A major earthquake has occurred within the vicinity of the local hospital. The nursing supervisor working the night shift at the hospital receives information that the hospital disaster plan will be activated. The supervisor will need to work with what organization responsible for coordinating interagency relief assistance? A. Office of Emergency Management B. Incident Command System C. Centers for Disease Control and Prevention (CDC) D. American Red Cross

office of emergency management

A patient with spinal cord injury is ready to be discharged home. A family member asks the nurse to review potential complications one more time. What are the potential complications that should be monitored for in this patient? Select all that apply. A) Orthostatic hypotension B) Autonomic dysreflexia C) DVT D) Salt-wasting syndrome E) Increased ICP

orthostatic hypotension autonomic dysreflexia DVT

A nurse is providing an in-service program for fellow emergency nurses about hypothermia and rewarming methods used. The nurse determines that the presentation was successful when the group identifies which of the following as a passive-active rewarming method? a. Over-the-bed heaters b. Warmed humidified oxygen by ventilator c. Forced warm air blankets d. Cardiopulmonary bypass

over-the-bed heaters

A hospitals emergency operations plan has been enacted following an industrial accident. While one nurse performs the initial triage, what should other emergency medical services personnel do? A. Perform life-saving measures. B. Classify patients according to acuity. C. Provide health promotion education. D. Modify the emergency operations plan.

perform life-saving measures

The nurse recognizes that a patient with a SCI is at risk for muscle spasticity. How can the nurse best prevent this complication of an SCI? A) Position the patient in a high Fowler's position when in bed. B) Support the knees with a pillow when the patient is in bed. C) Perform passive ROM exercises as ordered. D) Administer NSAIDs as ordered.

perform passive ROM exercises as ordered

A patient suffering from blast lung has been admitted to the hospital and is exhibiting signs and symptoms of an air embolus. What is the nurses most appropriate action? A. Place the patient in the Trendelenberg position. B. Assess the patients airway and begin chest compressions. C. Position the patient in the prone, left lateral position. D. Encourage the patient to perform deep breathing and coughing exercises.

place the patient in the prone, left lateral position

When preparing to perform abdominal thrusts on a client with an airway obstruction, which of the following would be most appropriate? a. Having the conscious client lie down b. Using a sequence of four thrusts, each progressing in intensity c. Placing the thumb side of one hand at the xiphoid process d. Positioning the hands in the midline slightly above the umbilicus

placing the thumb side of one hand at the xiphoid process

A nurse has been called for duty during a response to a natural disaster. In this context of care, the nurse should expect to do which of the following? A. Practice outside of her normal area of clinical expertise. B. Perform interventions that are not based on assessment data. C. Prioritize psychosocial needs over physiologic needs. D. Prioritize the interests of older adults over younger patients.

practice outside of her normal area of clinical expertise

The staff educator is precepting a nurse new to the critical care unit when a patient with a T2 spinal cord injury is admitted. The patient is soon exhibiting manifestations of neurogenic shock. In addition to monitoring the patient closely, what would be the nurse's most appropriate action? A) Prepare to transfuse packed red blood cells. B) Prepare for interventions to increase the patient's BP. C) Place the patient in the Trendelenberg position. D) Prepare an ice bath to lower core body temperature.

prepare for interventions to increase the patient's BP

A nurse is caring for a patient with burns who is in the later stages of the acute phase of recovery. The plan of nursing care should include which of the following nursing actions? A) Maintenance of bed rest to aid healing B) Choosing appropriate splints and functional devices C) Administration of beta adrenergic blockers D) Prevention of venous thromboembolism

prevention of VTE

The nursing supervisor at the local hospital is advised that your hospital will be receiving multiple trauma victims from a blast that occurred at a local manufacturing plant. The paramedics call in a victim of the blast with injuries including a head injury and hemorrhage. What phase of blast injury should the nurse expect to treat in this patient? A. Primary phase B. Secondary phase C. Tertiary phase D. Quaternary phase

primary phase

A patient is in the acute phase of a burn injury. One of the nursing diagnoses in the plan of care is Ineffective Coping Related to Trauma of Burn Injury. What interventions appropriately address this diagnosis? Select all that apply. A) Promote truthful communication. B) Avoid asking the patient to make decisions. C) Teach the patient coping strategies. D) Administer benzodiazepines as ordered. E) Provide positive reinforcement.

promote truthful communication teach the patient coping strategies provide positive reinforcement

A patient who was burned in a workplace accident has completed the acute phase of treatment and the plan of care has been altered to prioritize rehabilitation. What nursing action should be prioritized during this phase of treatment? A) Monitoring fluid and electrolyte imbalances B) Providing education to the patient and family C) Treating infection D) Promoting thermoregulation

providing education to the patient and family

A group of disaster survivors is working with the critical incident stress management (CISM) team. Members of this team should be guided by what goal? A. Determining whether the incident was managed effectively B. Educating survivors on potential coping strategies for future disasters C. Providing individuals with education about recognizing stress reactions D. Determining if individuals responded appropriately during the incident

providing individuals w/ education about recognizing stress reactions

A patient experienced a 33% TBSA burn 72 hours ago. The nurse observes that the patient's hourly urine output has been steadily increasing over the past 24 hours. How should the nurse best respond to this finding? A) Obtain an order to reduce the rate of the patient's IV fluid infusion. B) Report the patient's early signs of acute kidney injury (AKI). C) Recognize that the patient is experiencing an expected onset of diuresis. D) Administer sodium chloride as ordered to compensate for this fluid loss.

recognize that the patient is experiencing an expected onset of diuresis

The nurse is preparing the patient for mechanical débridement and informs the patient that this will involve which of the following procedures? A) A spontaneous separation of dead tissue from the viable tissue B) Removal of eschar until the point of pain and bleeding occurs C) Shaving of burned skin layers until bleeding, viable tissue is revealed D) Early closure of the wound

removal of eschar until the point of pain and bleeding occurs

The ED nurse is caring for a client who has been identified as a victim of physical abuse. In planning care for the client, which is the priority nursing action? 1. adhering to mandatory abuse-reporting laws 2. notifying the caseworker of the family situation 3. removing the client from any immediate danger 4. obtaining treatment for the abusing family member

removing the client from any immediate danger

A nurse is performing triage at the scene of a building collapse and is using a five-level triage system. Place the categories below in the proper order from most to least immediate.

resuscitation emergent urgent nonurgent minor

Emergency department (ED) staff members have been trained to follow steps that will decrease the risk of secondary exposure to a chemical. When conducting decontamination, staff members should remove the patients clothing and then perform what action? A. Rinse the patient with water. B. Wash the patient with a dilute bleach solution. C. Wash the patient chlorhexidine. D. Rinse the patient with hydrogen peroxide.

rinse the patient w/ water

A nurse is providing an educational program for a group of occupational health nurses working in chemical facilities. Which of the following would the nurse include as the priority in the case of a chemical burn?

rinsing the area w/ copious amounts of water

A patient is brought to the trauma center by ambulance after sustaining a high cervical spinal cord injury 1½ hours ago. Endotracheal intubation has been deemed necessary and the nurse is preparing to assist. What nursing diagnosis should the nurse associate with this procedure? A) Risk for impaired skin integrity B) Risk for injury C) Risk for autonomic dysreflexia D) Risk for suffocation

risk for injury

The nurse has commenced a transfusion of fresh frozen plasma (FFP) and notes the client is exhibiting symptoms of a transfusion reaction. After the nurse stops the transfusion, what is the next required action?

run a normal saline line to keep the vein open

A patient is brought to the emergency department following an overdose of a selective serotonin reuptake inhibitor (SSRI). While assessing the patient, the nurse suspects that the patient may be developing serotonin syndrome based on which of the following?

seizures

A client presents to the ED with a stab wound to the abdomen following an assault. It is suspected that the client has an injury to the pancreas. Which laboratory study is used to detect pancreatic injury?

serum amylase

Which guideline is appropriate for a nurse to implement while helping family members cope with the sudden death of a loved one? a. Show acceptance of the body by touching it, giving the family permission to touch. b. Inform the family that the client has passed on. c. Provide details of the factors attendant to the sudden death. d. Obtain orders for sedation for family members.

show acceptance of the body by touching it, giving the family permission to touch

A nurse is caring for a patient in the emergent/resuscitative phase of burn injury. During this phase, the nurse should monitor for evidence of what alteration in laboratory values? A) Sodium deficit B) Decreased prothrombin time (PT) C) Potassium deficit D) Decreased hematocrit

sodium deficit

A nurse takes a shift report and finds he is caring for a patient who has been exposed to anthrax by inhalation. What precautions does the nurse know must be put in place when providing care for this patient? A. Standard precautions B. Airborne precautions C. Droplet precautions D. Contact precautions

standard precautions

The nurse is helping a client w/ a SCI to establish a bladder retraining program. Which strategies may stimulate the client to void? SATA 1. stroking the client's inner thigh 2. pulling on the client's pubic hair 3. initiating intermittent catheterization 4. pouring warm water over the client's perineum 5. tapping the bladder to stimulate the detrusor muscle 6. reminding the client to void in a urinal every hour while away

stroking the client's inner thigh pulling on the client's pubic hair pouring warm water over the client's perineum tapping the bladder to stimulate the detrusor muscle

A nurse is providing inservice education for staff members about evidence collection after sexual assault. The educational session is successful when staff members focus their initial care on which step?

supporting the client's emotional status

The nurse is coordinating the care of victims who arrive at the ED after a radiation leak at a nearby nuclear plant. What would be the first intervention initiated when victims arrive at the hospital? A. Administer prophylactic antibiotics. B. Survey the victims using a radiation survey meter. C. Irrigate victims open wounds. D. Perform soap and water decontamination.

survey the victims using a radiation survey meter

The nurse is caring for a client in the intensive care unit who is recovering from trauma as a result of a motor vehicle accident that claimed the life of the client's friend. While the nurse is performing a dressing change on the client's surgical wound, the client states, "I don't deserve to live. I have just been thinking about ending it all." As the nurse assesses the client's imminent risk for suicide, what contributing factors need to be considered? Select all that apply.

the client attempted suicide as a teenager the client's maternal uncle committed suicide the client had a close relationship to the accident victim

A man survived a workplace accident that claimed the lives of many of his colleagues several months ago. The man has recently sought care for the treatment of depression. How should the nurse best understand the mans current mental health problem? A. The man is experiencing a common response following a disaster. B. The man fails to appreciate the fact that he survived the disaster. C. The man most likely feels guilty about his actions during the disaster. D. The mans depression most likely predated the disaster.

the man is experiencing a common response following a disaster

The nurse has been notified that the ED is expecting terrorist attack victims and that level D personal protective equipment is appropriate. What does level D PPE include? A. A chemical-resistant coverall with splash hood, chemical-resistant gloves, and boots B. A self-contained breathing apparatus (SCBA) and a fully encapsulating, vapor-tight, chemical resistant suit with chemical-resistant gloves and boots. C. The SCBA and a chemical-resistant suit, but the suit is not vapor tight D. The nurses typical work uniform

the nurses typical work uniform

While performing a patient's ordered wound care for the treatment of a burn, the patient has made a series of sarcastic remarks to the nurse and criticized her technique. How should the nurse best interpret this patient's behavior? A) The patient may be experiencing an adverse drug reaction that is affecting his cognition and behavior. B) The patient may be experiencing neurologic or psychiatric complications of his injuries. C) The patient may be experiencing inconsistencies in the care that he is being provided. D) The patient may be experiencing anger about his circumstances that he is deflecting toward the nurse.

the patient may be experiencing anger about his circumstances that he is deflecting toward the nurse

A 44-year-old male patient has been exposed to severe amount of radiation after a leak in a reactor plant. When planning this patients care, the nurse should implement what action? A. The patient should be scrubbed with alcohol and iodine. B. The patient should be carefully protected from infection. C. The patients immunization status should be promptly assessed. D. The patients body hair should be removed to prevent secondary contamination.

the patient should be carefully protected from infection

A nurse on the neurologic unit is providing care for a patient who has spinal cord injury at the level of C4. When planning the patient's care, what aspect of the patient's neurologic and functional status should the nurse consider? A) The patient will be unable to use a wheelchair. B) The patient will be unable to swallow food. C) The patient will be continent of urine, but incontinent of bowel. D) The patient will require full assistance for all aspects of elimination

the patient will require full assistance for all aspects of elimination

A patient who suffered a spinal cord injury is experiencing an exaggerated autonomic response. What aspect of the patient's current health status is most likely to have precipitated this event? A) The patient received a blood transfusion. B) The patient's analgesia regimen was recent changed. C) The patient was not repositioned during the night shift. D) The patient's urinary catheter became occluded.

the patient's urinary catheter became occluded

An emergency department nurse has just admitted a patient with a burn. What characteristic of the burn will primarily determine whether the patient experiences a systemic response to this injury? A) The length of time since the burn B) The location of burned skin surfaces C) The source of the burn D) The total body surface area (TBSA) affected by the burn

the total body surface area (TBSA) affected by the burn

A nurse is developing a care plan for a patient with a partial-thickness burn, and determines that an appropriate goal is to maintain position of joints in alignment. What is the best rationale for this intervention? A) To prevent neuropathies B) To prevent wound breakdown C) To prevent contractures D) To prevent heterotopic ossification

to prevent contractures

A patient with a partial-thickness burn injury had Biobrane applied 2 weeks ago. The nurse notices that the Biobrane is separating from the burn wound. What is the nurse's most appropriate intervention? A) Reinforce the Biobrane dressing with another piece of Biobrane. B) Remove the Biobrane dressing and apply a new dressing. C) Trim away the separated Biobrane. D) Notify the physician for further emergency-related orders.

trim away the separated Biobrane

The nurse is preparing to admit patients who have been the victim of a blast injury. The nurse should expect to treat a large number of patients who have experienced what type of injury? A. Chemical burns B. Spinal cord injury C. Meningeal tears D. Tympanic membrane rupture

tympanic membrane rupture

Which category of triage encompasses clients with serious health problems that are not immediately life threatening?

urgent

A patient who is being treated in the hospital for a spinal cord injury is advocating for the removal of his urinary catheter, stating that he wants to try to resume normal elimination. What principle should guide the care team's decision regarding this intervention? A) Urinary retention can have serious consequences in patients with SCIs. B) Urinary function is permanently lost following an SCI. C) Urinary catheters should not remain in place for more than 7 days. D) Overuse of urinary catheters can exacerbate nerve damage.

urinary retention can have serious consequences in patients w/ SCIs

The nurse educator is discussing emerging diseases with a group of nurses. The educator should cite what causes of emerging diseases? Select all that apply. A) Progressive weakening of human immune systems B) Use of extended-spectrum antibiotics C) Population movements D) Increased global travel E) Globalization of food supplies

use of extended-spectrum ABX population movements increased global travel globalization of food supplies

A nurse has had contact with a patient who developed smallpox and became febrile after a terrorist attack. This nurse will require what treatment? A. Watchful waiting B. Treatment with colony-stimulating factors (CSFs) C. Vaccination D. Treatment with ceftriaxone

vaccination

When assessing patients who are victims of a chemical agent attack, the nurse is aware that assessment findings vary based on the type of chemical agent. The chemical sulfur mustard is an example of what type of chemical warfare agent? A. Nerve agent B. Blood agent C. Pulmonary agent D. Vesicant

vesicant